Notification

Day Rehabilitation


Notification Issue Date: 12/13/2019

This version of the policy will become effective 01/13/2020.

This policy has been updated in consideration of existing Evidence of Coverage revisions for Maintenance Therapy.



Medicare Advantage Policy

Title:Day Rehabilitation
Policy #:MA10.005b

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY

Day rehabilitation is considered medically necessary and, therefore, covered when the individual has a rehabilitation diagnosis (e.g., traumatic brain injury, cerebrovascular accident, spinal cord injury) and all of the following criteria are met:
  • The day rehabilitation program is being prescribed to address the individual's extensive rehabilitation needs. The individual must require the multiple intensive therapies and coordinated care typically provided in an acute inpatient rehabilitation level of care but does not require the medical and nursing supervision provided in acute inpatient rehabilitation 24 hours a day.
  • The individual is medically stable.
  • The individual has an adult primary caregiver at home who is able to provide assistance in integrating the rehabilitation program into the home.
  • The individual must require at least four to seven hours of rehabilitative therapies per day, five days per week, and may also require other medical services.
    • The individual must require at least two of the following rehabilitative therapy services:
      • Physical therapy
      • Occupational therapy
      • Speech therapy
    • Other medical services may include but are not limited to:
      • Nursing care
      • Psychological therapy
      • Case management
  • The individual is expected to functionally improve and has appropriate rehabilitation goals that warrant a day rehabilitation program.
  • The individual has the ability to communicate (verbally or non-verbally) basic needs*.
  • The individual is able to consistently follow directions and manage his/her behavior with minimal to moderate intervention by professional staff*.
  • The individual is willing to participate in a day rehabilitation program*.

*These criteria should be evaluated by giving deference to the individual's current medical condition (e.g., age, developmental status, injury, and/or impairment) and the requirements and goals of the day rehabilitation program (e.g., a day rehabilitation program structured for a pediatric patient with a traumatic brain injury).

Maintenance therapy is considered medically necessary and therefore, covered when the specialized skill, knowledge and judgement of a qualified professional is required to establish, instruct and carry out a program to maintain the individual's current condition or to prevent or slow further deterioration. Documentation with objective evidence or a clinically supportable statement is needed to support the necessity of the skilled services provided and the individual's response to treatment.

For most of the Company's products, day rehabilitation has visit limitations. Individual member benefits must be verified.


NOT MEDICALLY NECESSARY

If the above criteria are not met, day rehabilitation is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury. Additionally, when therapy services can be provided in a traditional outpatient setting, day rehabilitation is not medically necessary and, therefore, not covered in lieu of traditional outpatient therapy.

Maintenance therapy is considered not medically necessary, and, therefore, not covered in the following circumstances when the professional skills of a qualified professional are not required:
  • Services related to activities for the general good and welfare of individuals (e.g., general exercises to promote overall fitness and flexibility)
  • Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such as that provided in support for feeble or unstable individuals
  • Range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities
  • Therapies after the individual has achieved therapeutic goals
  • Therapy services performed by the individual alone or with the assistance of a family member or unskilled caregiver


REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

For individuals transitioning from another level of care (e.g., acute rehabilitation) and being referred to a day rehabilitation program, a list of short- and long-term goals should be provided to the day rehabilitation program.

The medical record should include the plan of care that has been written and developed by the eligible health care provider. The plan of care must be established prior to the initiation of therapy and signed by the provider.

The plan of care should include the following information:
  • The individual's significant history
  • The individual's diagnoses that require therapy
  • Any related professional provider's orders
  • The goals for therapy, which should be specific and measurable, and the expected potential for achievement, which should include the type, amount, duration, and frequency of therapy services
  • Any contraindications to a course of therapy
  • The individual's awareness and understanding of the diagnoses, prognoses, and goals of therapy
  • The development of a maintenance program while therapy is being provided
  • When appropriate, a summary of past therapies and the results that were achieved

Daily treatment notes should include the following information:
  • Date of treatment
  • Specific treatment provided
  • Response to treatment
  • Skilled ongoing reassessment of the individual’s progress towards established goals
  • Objective, measurable, and specific documentation of progress towards goals using consistent and comparable methods
  • Changes to plan of care or objective reasoning for why the individual has not progressed towards goals
  • Name and credentials of the treating clinician
    Policy Guidelines

Acute inpatient therapy services are intensive (at least three hours a day, five to seven days per week), consisting of at least two rehabilitative therapies, other associated medical services (e.g., case management), with 24 hours of medical and nursing supervision. Services are generally performed in a rehabilitation unit within a hospital or in a free-standing rehabilitation hospital.


Traditional outpatient therapy services are moderately intensive multi-disciplinary services performed in an outpatient facility. The individual may receive all three rehabilitative therapy disciplines, but will typically receive one hour of each rehabilitative therapy three days per week.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, day rehabilitation is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as not medically necessary or not covered by Medicare are not eligible for coverage or reimbursement by the Company.


Description

Day rehabilitation programs are intensive, multidisciplinary, and comprehensive. They typically consist of four to seven hours of daily rehabilitative therapies (i.e., physical therapy, occupational therapy, speech therapy) five days per week and include a combination of one-to-one and group therapy. A component of a day rehabilitation program may include other medical services that include psychological therapy, nursing, and case management. Day rehabilitation programs are offered in an outpatient setting, and the individual returns home each evening and for the entire weekend. Day rehabilitation programs are provided when the individual requires the intensity of acute inpatient rehabilitation but does not require the medical and nursing supervision provided in acute inpatient rehabilitation 24 hours a day.

Maintenance therapy consists of activities that preserve the individual's level of function or prevent regression of that function. Maintenance begins when the therapeutic goals of a plan of care have been achieved or when no further progress is apparent or expected to occur.
References

Braddom R. Physical Medicine and Rehabilitation.2nd edition. Philadelphia, PA. Saunders; 2000.

Centers for Medicare and Medicaid Services. Medicare Benefit Hospital Manual.Chapter 1 - Inpatient Hospital Services Covered Under Part A. [CMS Web site]. 03/10/2017. Available at: http://www.cms.hhs.gov/manuals/downloads/bp102c01.pdf. Accessed September 6, 2019

Centers for Medicare and Medicaid Services. Medicare Benefit Hospital Manual.Chapter 12 - Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage. [CMS Web site]. 01/25/2019. Available at: https://www.cms.gov/manuals/Downloads/bp102c12.pdf. Accessed September 6, 2019.

Centers for Medicare and Medicaid Services. Medicare Benefit Hospital Manual.Chapter 15 - Covered Medical and Other Health Services [CMS Web site]. 07/12/2019. Available at: http://www.cms.gov/manuals/downloads/bp102c15.pdf. Accessed September 6, 2019.

Crotty M, Giles LC, Halbert J, et al. Home versus day rehabilitation: a randomized controlled trial. Age Aging. 2008;37(6):628-633.

Frontera WR, Silver JK, et al. Essentials of Physical Medicine and Rehabilitation. 2nd edition. New York, NY. Saunders; 2008.

Hashimoto K, Takatsugu O, et al. Effectiveness of a comprehensive day treatment program for rehabilitation of patients with acquired brain injury in Japan. J Rehabil Med.2006;38(1):20-25.

Hershkovitz A, Beloosesky Y, Brill S, et al. Is a day rehabilitation programme associated with reduction of handicap in stroke patients? Clin Rehabil.2004;18:261-266.

Kathrins B, Kathrins R, Marsico R, et al. Comparison of day rehabilitation to skilled nursing facility for the rehabilitation for total knee arthroplasty. Am J Phys Med Rehabil. 2013;92(1):61-7.

Olsson BG, Sunnerhagen KS. Effects of day hospital rehabilitation after stroke. J Stroke Cerebrovasc Dis. 2006;15(3):106-113.

Olsson BG, Sunnerhagen KS. Functional and cognitive capacity and health-related quality of life 2 years after day hospital rehabilitation for stroke: a prospective study. J Stroke Cerebrovasc Dis.2007;16(5):208-215.

Specialty-Matched Consultant Review.

Wilson CF, Wheatley-Smith L, Downes C. Analysis of intensive outpatient neuro-rehabilitation outcomes using FIM+FAMUK. NeuroRehabil.2009;24:377-382.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)



THE FOLLOWING CODES ARE USED TO REPRESENT DAY REHABILITATION

0931 Medical rehabilitation day program half day

0932 Medical rehabilitation day program full day

Coding and Billing Requirements






Policy History

MA10.005b
01/13/2020This version of the policy will become effective 01/13/2020.

This policy has been updated in consideration of existing Evidence of Coverage revisions for Maintenance Therapy.

Revisions from MA10.005a
06/06/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Day Rehabilitation.
05/24/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Day Rehabilitation.
03/30/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Day Rehabilitation.
02/11/2015Updated policy number MA10.005a will become effective 02/11/2015. The policy was updated to reflect the company's continuing coverage position on day rehabilitation services.

Revisions from MA10.005
01/01/2015This is a new policy.






Version Effective Date: 01/13/2020
Version Issued Date: 01/13/2020
Version Reissued Date: N/A